Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Sunday, November 23, 2008

I recently linked to an article on the Well Blog about a child with Asperger's Syndrome in NYC. The boy's parents were at odds with their housing co-op about the boy's need for an emotional support dog in the no-pets-allowed complex.

Roy said that's what docs get to do: determine medical necessity.Commenters on our blog and the Well blog were mixed, and I really don't have enough facts to feel comfortable commenting on the situation.

It did get me thinking about the concept of Medical Necessity and before I start rambling, let me say that I didn't see the term "medical necessity" on anything associated with the kid and dog case. What I read simply said that doctors thought a dog would help the boy, that the co-op agreed to let him have a small dog with many stipulations attached, and the feds, specifically HUD, took on the cause and felt the co-op discriminated against the family. You can read Here.Medical Necessity is a funny concept, one I'm not always 100% comfortable with. I think the issue here is that when we as physicians deem something Medically Necessary, it implies some imposition, usually financial, but in the case of the service dog--furry-- on someone else. Usually we use the term to mean that it's something someone's health insurance should pay for that they don't (or may not want to) pay for. If there's not a cost (financial or otherwise), then one can leave it at "My doctor said to do ...." and there's not a reason to deem it "medically necessary." That's a term that goes in writing and means someone, somewhere will find it inconvenient.

I don't usually declare that things are Medically Necessary from a psychiatric viewpoint, except for specific medications-- sometimes Name Brands (as opposed to generics) and then because the patient has tried the generic and found that either they don't work as well or they cause side effects. The other Medically Necessary things I recommend are sessions (ie, treatment is medically necessary) or Hospitalization...ah, the joys of managed care. Sometimes I tell people to stay home from work, especially if I feel their behavior during an episode of illness puts them in jeopardy, and I'll write a note saying they need time off, or that they were at a doctors' appointment, but this usually doesn't require a statement of medical necessity, per se, it falls under sick leave. My stationery doesn't even say I'm a shrink, and unless I'm specifically asked, I don't volunteer that in "doctor's excuse" notes.

In the case of the dog and the kid, the term "medically necessary" wasn't used-- it was simply said that the dog might be helpful to the boy. What about another occupant who might require a animal-free environment? How do we determine whose rights trump whose? Maybe this is a bad example, because one can envision that one condo owner could live with a dog in such a way that the other people in the condo aren't disturbed by it and the presentation by the press left the reader feeling that the complex owners are unsympathetic child and dog hating meanies who were being unnecessarily arbitrary. I got curious and did a little googling-- it seems the dog would be going through a training process with the boy. The other issue was concern by the building about the area around the entrance to doctors' offices in the building.

So this is my concern with extending the definition of what is a disabilty and what we should do as a society to accommodate the needs of the disabled: if the issues get too diffuse, then ultimately the laws to protect the disabled hurt them. Don't want any autistic kids here because then we'll have to allow their dogs. Okay, maybe that's silly, but the issue isn't just what one group needs, it's also the fear of being sued because of the perception of injustice, or the fear of having to accomodate. The issue of medical necessity feeds into this unless we hold to a fairly strict notion of what is medically necessary, and as doctors.

If you want to read more about the kid with the battle for the dog:Try this or this.

And just to be clear, this is a rambling post. Most often, 'medical necessity' is a term that has to do with Medicare reimbursement...somehow I've gone off about service dogs and co-ops and broader implications to society.

9
comments:

This is a good example of how we try to balance the needs of patients (for forbearance in terms of time off or disability or whatever) and the needs of society (the needs of employers not to have their workers out sick, the needs of taxpayers not to have their taxes used unnecessarily for the disability system).

However, these decisions often have more of a a BS component than people realize. One week off from work--why not three days, or ten? Another of the less than scientific aspects of what we do.

In general, not enough is done to help the disabled and we'd have to go a long way as a society that we'd be erring in the opposite direction.

I am in the camp of those who think the condo complex is imposing unfair rules. For example, an adult dog can be left alone more than 2 hours without problems. It's also outrageous they will not allow the dog on the family's private terrace.

I don't know, I really don't think that about 90% of what people demand as "medical necessity" really is. But I guess I'm an example of the medical training process which expects you to be superhuman and beat all sympathy for weakness out of you.

I hope you never tell employers etc that you are a shrink...I always say I'd never sue a doctor, even on a "wrong leg surgery" but the one thing I would is breach of confidentiality.

As with most invocations of authority, I think medical necessity is usually a last resort to circumvent failures of compassion or creative problem-solving. It's too bad that it ever has to be called upon as an explanation for courses of action that really fall under the category of common sense, as in the case of your patient who may need time off work during a bad episode; it would be nice if employers, and society in general, were more understanding.

Novalis: agreed, it would be nice if this were more exact. With the exception of patients who are acutely homicidal, the physician's interest has to be for his individual patient, not for society as a whole

MWAk: Stay tuned?

Shruti: thanks.

TP: agreed... seems that given the building is full of people that have bought condos with a no-pets policy, that the issue should be the training of the dog to assure it's a service animal and not going to bark or jump on people, and not how long it's left alone (service dogs don't bark, right?) or if the boy needs a dog, it should be with him in school..and if the dog doesn't pee off the balcony... but I have no real clue here...just bending this in my own head.

s: psychiatrists don't generally communicate with employers-- if a patient needs a note for work, I give it to the patient to do with what they want-- I write it in their presence and hand it to them.

David Rochester:The 'medical necessity' issue is a term used mostly to justify treatment for Medicare or insurance companies

Thanks for post. I had read this article when it came out but had not looked at the comments page until I read about it again on this blog.

What is interesting is that if you compare different articles, some mention the word "service dog" and others just mention "dog" - and there is a distinct difference between the two. Also, like you said, some articles say the dog would be "helpful" while others say that he has been prescribed a service dog. So which is it?

I guess the co-op board should be thankful he wanted a dog and not a miniature horse.

In general, the service animal concept bothers me because the language written for the accommodations is vague, leaving too many openings for loopholes.

Medical necessity is a changed concept. It used to be that medical knowledge and propriety was respected and humanity permitted such privileges. However, in increasingly capitalist and selfish times - medical necessity now also covers making social and moral judgment.

Social moral standards are not what they were. No one has a neighbour anymore and apologies are metered in measures of avoiding litigatory dollars rather than sincerity.

Medical necessity is a residual option to redress the balance where such amoralistic selfishness prevails.

If it were my choice on the dog - if it may be of benefit why should he be denied the option at quality of life improvement at the drop of one concern?Resident A is allergic to dogs? I don't proscribe imposing one persons disability is another man's misfortune - but society should be more tolerant of others - in whatever capacity. If there's an equally genuine QoL issue against dog moving in then ok, make boy and dog a better option to move in elsewhere without allergic neighbours. If not available, social policy should make it available.The more widely an idea may be of benefit - the more important it is to make it available. Dogs and improved quality of life are potentially a great benefit and avoid or diminish a potential for long term social and medical intervention. Such a matter is in the intersts of everyone - not just suffering boy - and should be given the extra effort.